Filling Up the Valleys

September 2019 | Volume 18 | Issue 9 | Features | 957 | Copyright © September 2019

James M. Swinehart MD

Denver, CO

Scars or defects are first undermined with a Nokor needle to create a pocket. Nasolabial folds are first undermined with a Nokor needle, and then widened with a metal probe. Smaller grafts are inserted with jeweler's forceps into the defect or scar, and a surgical snare is used to pull the "Julienne strip" through the nasolabial folds, leaving excess tissue visible at the top and bottom. All of these incisions (each 1 to 2 mm in size) are then closed with 5/0 or 6/0 Vicryl sutures to prevent extrusion of the grafts, followed by steri-strips with adhesive. A dressing is applied generally with Telfa and Hypafix.
James M. Swinehart MD
Denver, CO

References
1. Swinehart, JM. Dermal grafting. Dermatologic Clinics. 2001;19(3).

2. Swinehart, JM. Dermal pocket grafting: implants of dermis, fat, and"autologous collagen" for permanent correction of cutaneous depressions.International Journal of Aesthetic and Restorative Surgery. 1994;2(1):43-52.

Sanding Down the Mountain

Many acne scars are 1mm to 2mm deep, and any laser (if one exists) that can penetrate more than 100 microns (= 0.1mm) deep runs a large risk of scarring from the heat generate. Manual dermabrasion, whether via wire brush, or diamond fraise, dermasanding, is, and has been, the gold standard for the treatment of acne scarring and deep facial lines.

The 5 keys to a successful full-face wire brush dermabrasion include:
1) Adequate oral sedation, nerve blocks, and tumescentanesthesia.

2) The mandatory use of an aerosol spray, -30° F to -60° F tocreate temporary rigidity that negates the rubbery textureof skin and prevents skipping of the dermabrasion wheel.

3) The "triangular stretch" technique for each patch, generally4cm x 4cm. Two of the triangles are stretched by the medical assistant and one by the physician's non-dominant hand,using sterile cloth towels. The cloth towels are also usedto protect the eyes, ears, nose, and mouth during thespraying procedure.

4) Proper depth selection, with the wire brush extending intothe reticular dermis (where fine striated lines are visible)but not into the deep dermis (a ragged appearance impliesthat you have gone too deeply).

5) A wire brush is used for larger scars and/or lines, whereasa diamond fraise will penetrate less deeply.

6) Edge feathering with chemical peeling and/or the use of adiamond fraise described below.

Patient Selection: Test spots performed at least 4 weeks prior to the procedure are nearly always mandatory and help deselect the 1% of patients who might develop a scar from the procedure. They also give the patient reassurance that the procedure will be effective, generally performed on a very small scar or wrinkled area.

Preoperatively, consent is obtained, lab work is performed, and preoperative photos are taken. Prescriptions are given for antibiotics, a Medrol DosePak, and Acyclovir if there is any history of herpes simplex.

Pre-op sedation is obtained with oral Valium, Meclizine, and Oxycodone or Hydrocodone, followed by tumescent anesthesia, inserted after the performance of blocks of the supraorbital, supratrochlear, lateral zygomaticotemporal, paranasal, mental, and marginal mandibular nerves. Proper overhead lighting is mandatory, and magnification may be of benefit to the surgeon.